Informed consent

Informed consent is a legal doctrine that has been developed
by the courts over a number of years. The doctrine of informed consent
may have been derived from the Nuremberg
Code, which required that doctors obtain the voluntary informed
consent of the subject prior to conducting medical experimentation.
The Informed Consent Doctrine requires that medical doctors provide
a patient with all relevant information about a proposed procedure or
treatment prior to obtaining the consent of the patient to carry out
the procedure or treatment. Four items of information that must be provided
are:

the nature of the procedure

the risks

the benefits

the availability of alternative treatment (including no treatment)
and the risks and benefits thereof.

Informed consent protects the patient by providing him/her with complete
information on which to make an informed decision. Informed consent
usually also protects the doctor from financial liability (with exceptions)
provided that the procedure is properly executed according to the prevailing
standard of care and without negligence. The adult patient's power to
consent is very broad and includes the power to consent to such extreme
operations as sexual reassignment. Inadequate provision of information,
however, may invalidate the consent.

Informed consent in pediatrics

When the patient is incompetent as in the case of a child or an incompetent
adult, a parent or other guardian usually gives surrogate consent. Parents
are expected to exercise their power to consent only in the best interests
of the child. Courts have narrowed the powers of consent by proxies.
Proxies usually may only consent to procedures which are beneficial
to the patient. An infant can neither be informed nor give consent for
surgery, such as circumcision. This raises a serious ethical and legal
question for physicians and parents.

The American Academy of Pediatrics issued an official policy statement regarding informed consent
in pediatric practice in 1995 [Pediatrics 1995;95:314-317]. A
number of statements in this report are relevant to circumcision, such
as the following:

"We now realize that the doctrine of 'informed consent' has only
limited direct application in pediatrics. Only patients who have appropriate
decisional capacity and legal empowerment can give their informed
consent to medical care. In all other situations, parents or other
surrogates provide informed permission for diagnosis and treatment
of children with the assent of the child whenever appropriate."

"Parents and physicians should not exclude children and adolescents
from decision-making without persuasive reasons."

"Thus 'proxy consent' poses serious problems for pediatric health
care providers. Such providers have legal and ethical duties to their
child patients to render competent medical care based on what the
patient needs, not what someone else expresses."

"A patient's reluctance or refusal to assent should also carry considerable
weight when the proposed intervention is not essential to his or her
welfare and/or can be deferred without substantial risk."

Consent form

At the present time, the legal problems notwithstanding, the medical
practice is to obtain the written consent of a parent to the circumcision
of a male child before a circumcision is carried out. (In the United
Kingdom, a court
decision requires that doctors obtain the written consent of both
parents for non-therapeutic circumcision of a child.)

A circumcision that is performed without valid consent is a wrongful
circumcision. Wrongful circumcisions not infrequently result in
litigation to recover damages on behalf of the child for the pain,
suffering, and permanent
injury to the penis, so most doctors and institutions will not
perform a circumcision without a signed consent form.

Many hospitals/doctors do not provide parents with complete information
on which to make a truly informed decision. (There is an inherent
conflict of interest between the hospital's/doctor's desire to perform
a circumcision and collect a fee and the right of the patient and/or
his representative to be fully informed.) Therefore, few American
parents are fully informed of the nature of neonatal circumcision
and of the known risks and disadvantages associated with infant circumcision.
To inform parents, NOCIRC presents a model informed consent for
circumcision form, which may be used universally. A model consent
form that presents the information parents should know prior to granting
consent for circumcision, written by pediatrician Dr. Robert Van Howe,
is available here.